imagistica in bolile pulmonare

7/30/2019 Imagistica in Bolile Pulmonare

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IMAGISTICA IN BOLILEIMAGISTICA IN BOLILE

PULMONAREPULMONARECLINICA MEDICALA CARITASCLINICA MEDICALA CARITAS


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Rx PULMONARRx PULMONAR Imagine standardImagine standard

postero-anterioara, laterala sau oblicapostero-anterioara, laterala sau oblica

in inspir profundin inspir profund

simetrica (claviculele simetrice fata desimetrica (claviculele simetrice fata de

manubriul sternal)manubriul sternal)

distanta de 2 m intre tubul focal si ecran,distanta de 2 m intre tubul focal si ecran, Imagine antero-posterioara: umbra corduluiImagine antero-posterioara: umbra cordului

pare mai marepare mai mare


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ANATOMIA RADIOLOGICAANATOMIA RADIOLOGICA


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CT TORACICCT TORACIC

CT:CT: sectiuni anatomice fara imagini de sumatiesectiuni anatomice fara imagini de sumatie

Rezolutie de 10 ori mai mareRezolutie de 10 ori mai mare CT multislice: achizitionare de imagini continue,CT multislice: achizitionare de imagini continue,

isotropice, cu posibilitati de reconstructie bi sauisotropice, cu posibilitati de reconstructie bi sau

tridimensionala de inalta fidelitate, in orice plantridimensionala de inalta fidelitate, in orice plan

CT cu rezolutie inalta: frecventa spatilala inalta ceCT cu rezolutie inalta: frecventa spatilala inalta ce

evidentiaza detalii anatomiceevidentiaza detalii anatomice


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RMNRMN

RMNRMN Depinde de proprietatile magnetice ale atomilor de H;Depinde de proprietatile magnetice ale atomilor de H;

Mediul molecular inconjurtor afecteaza rata cu careMediul molecular inconjurtor afecteaza rata cu care

atomii de H elibereaza energieatomii de H elibereaza energie Aceasta energie duce la o distribuite spatiala aAceasta energie duce la o distribuite spatiala a

semnalelor care este convertita in imaginisemnalelor care este convertita in imagini

Specificitate pentru tesuturile moiSpecificitate pentru tesuturile moi

Evalueaza invazia peretelui toracic, infiltrareaEvalueaza invazia peretelui toracic, infiltrareamediastinala, invazia diafragmului in neoplaziimediastinala, invazia diafragmului in neoplazii

pulmonare sau plerualepulmonare sau pleruale


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PET SI ECOGRAFIAPET SI ECOGRAFIA

Positron Emission TomographyPositron Emission Tomography Fluorodeoxyglucose positron emission tomographyFluorodeoxyglucose positron emission tomography

(FDG-PET) foloseste fluorodeoxyglucose marcata(FDG-PET) foloseste fluorodeoxyglucose marcatapentru a evidentia calea glicolitica a celulelor tumoralepentru a evidentia calea glicolitica a celulelor tumorale

sau a altor celule metabolic active avide de glucozasau a altor celule metabolic active avide de glucoza Tumorile intratoracice;Tumorile intratoracice; evaluarea nodulilor pulmonari solitari .evaluarea nodulilor pulmonari solitari .

Ecografia:Ecografia: revarsatele pleurale: mai sensibila ca Rx (10 ml lichid)revarsatele pleurale: mai sensibila ca Rx (10 ml lichid) Semnul cozii de cometa in edemul pulmonarSemnul cozii de cometa in edemul pulmonar


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Bolile difuze pulmonareBolile difuze pulmonare Bolile difuze pulmonareBolile difuze pulmonare

alveolar versus interstitiale: nu exista o corelatie intre aspectul RX sialveolar versus interstitiale: nu exista o corelatie intre aspectul RX silocalizarea HP (alveolara sau interstitiala).localizarea HP (alveolara sau interstitiala).

Nu se mai recomanda distinctia: infiltrat alveolar/ infiltrat interstitialNu se mai recomanda distinctia: infiltrat alveolar/ infiltrat interstitial Aspectul nodular poate fi dat de boli alveolare dar si interstitialeAspectul nodular poate fi dat de boli alveolare dar si interstitiale Bolile alveolare pot produce reactie interstitialaBolile alveolare pot produce reactie interstitiala Aspectul de geam mat poate fi indus de bolile alveolare sau interstitialeAspectul de geam mat poate fi indus de bolile alveolare sau interstitiale

Bronhograma aerica, considerata patognomonica pentru bolile alveolareBronhograma aerica, considerata patognomonica pentru bolile alveolareapare, rar, si in boli interstitiale:apare, rar, si in boli interstitiale: SarcoidozaSarcoidoza Limfom pulmonarLimfom pulmonar Calcinoza pulmonara.Calcinoza pulmonara.

Se recomanda renuntarea la termenul infiltratSe recomanda renuntarea la termenul infiltrat Dg se pune pe analiza combinata a :Dg se pune pe analiza combinata a :

Tipului predominent de opacitati: macronodulare: > 1 cm;Tipului predominent de opacitati: macronodulare: > 1 cm;micronodulare : < 1 cmmicronodulare : < 1 cm

Volumul pulmonarVolumul pulmonar Distributia leziunilor predominant opacities, assessment of lung expansion,Distributia leziunilor predominant opacities, assessment of lung expansion,

and distribution and profusion of disease yields a differential diagnosis.and distribution and profusion of disease yields a differential diagnosis.


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Opacitati mariOpacitati mari Opacitatile mariOpacitatile mari::

Difuze omogenDifuze omogen::

leziuni difuze alveolareleziuni difuze alveolare Edem pulmonar (noncardiogenic ),Edem pulmonar (noncardiogenic ), Pneumonie virala difuza sau cuPneumonie virala difuza sau cu Pneumocystis jiroveciPneumocystis jiroveci

Opacitati multifocaleOpacitati multifocale bronchopneumonia,bronchopneumonia, Aspiratie recurentaAspiratie recurenta vasculitis.vasculitis.

Opacitati lobare fara atelectazieOpacitati lobare fara atelectazie:: Pneumonia lobaraPneumonia lobara

Opacitati lobare cu atelectazieOpacitati lobare cu atelectazie Obstructia unei bronhii lobare cu obstruction of a lobar cu corpi straini, tumori, mucusObstructia unei bronhii lobare cu obstruction of a lobar cu corpi straini, tumori, mucus

Opacitati perihilareOpacitati perihilare :: Edem pulmonar cardiogen din insuficienta cardiaca, insuficienta renala, supraincarcarea de volum, hemoragii pulmonare.Edem pulmonar cardiogen din insuficienta cardiaca, insuficienta renala, supraincarcarea de volum, hemoragii pulmonare.

CLASSIFICAREA OPACITATILOR MARICLASSIFICAREA OPACITATILOR MARI

Difuze omogeneDifuze omogene

MUltifocaleMUltifocaleLobar fara atelectazieLobar fara atelectazie

Lobar cu atelectazieLobar cu atelectaziePerihilarePerihilarePerifericePeriferice


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FIGURE 84-1FIGURE 84-1A, Patient with diffuse alveolar damage.A, Patient with diffuse alveolar damage. Chest radiograph shows diffuse homogeneous opacificationChest radiograph shows diffuse homogeneous opacification

of both lungs with clearly visible air bronchograms.of both lungs with clearly visible air bronchograms. B,B, Patient with acute varicella pneumonia. Chest radiographPatient with acute varicella pneumonia. Chest radiograph

demonstrates multiple acinar nodules with tendency for confluence, yielding multifocal patchy parenchymaldemonstrates multiple acinar nodules with tendency for confluence, yielding multifocal patchy parenchymal

opacification.opacification.


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FIGURE 84-2FIGURE 84-2 Patient with hydrostatic pulmonary edema due to left-sided heart failure.Patient with hydrostatic pulmonary edema due to left-sided heart failure. ChestChest

frontal radiograph demonstrates classic batwing distribution of pulmonary edemafrontal radiograph demonstrates classic batwing distribution of pulmonary edema..


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Opacitati miciOpacitati mici

Micronodulare: noduli < 1 mm,Micronodulare: noduli < 1 mm, Granulomatoza la talc la consumatorii de droguri iv,Granulomatoza la talc la consumatorii de droguri iv, Microlitiaza alveolaraMicrolitiaza alveolara Cazzuri rarre de silicozaCazzuri rarre de silicoza talcosis,talcosis, coal workers' pneumoconiosis ,coal workers' pneumoconiosis , BerylliumBeryllium rar sarcoidosis sau hemosiderosis.rar sarcoidosis sau hemosiderosis.

Nodulare: > 1 cmNodulare: > 1 cm Granuloame inflamatorii sau infectioase: miliare TBC, sarcoidoza, infectii fungice, alveolitaGranuloame inflamatorii sau infectioase: miliare TBC, sarcoidoza, infectii fungice, alveolita

alergica extrinseca, histiocitoza Langerhansalergica extrinseca, histiocitoza Langerhans

Tipuri de opacitati mici pulmonareTipuri de opacitati mici pulmonare

MicronodulareMicronodulare

AcinareAcinareLineareLineareReticulareReticulareBronhiceBronhiceArterialeArterialeDistructiveDistructive


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FIGURE 84-3FIGURE 84-3Patient with known transfusion reaction.Patient with known transfusion reaction. Chest radiograph displays ground-glassChest radiograph displays ground-glass

opacification of both lungs and bilateral Kerley's A lines, presenting as long linear structuresopacification of both lungs and bilateral Kerley's A lines, presenting as long linear structures

extending from the hilar regions into the pulmonary periphery.extending from the hilar regions into the pulmonary periphery.


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Opacitati liniareOpacitati liniare

Opacitatile liniare (liniile Kerley): ingrosarea septurilor interlobulare.Opacitatile liniare (liniile Kerley): ingrosarea septurilor interlobulare. Liniile Kerley A:Liniile Kerley A:

pleaca de la hil, 2 - 4 cm spre periferia plamanului, mai ales spre lobii superiori;pleaca de la hil, 2 - 4 cm spre periferia plamanului, mai ales spre lobii superiori; Reflecta ingrosarea interstitiului axialReflecta ingrosarea interstitiului axial Insuficienta ventriculara stangaInsuficienta ventriculara stanga reactii alergicereactii alergice

Liniile Kerley B:Liniile Kerley B: 1 cm lungime si 1 mm grosime1 cm lungime si 1 mm grosime La periferia lobilor inferiori, subpleuraliLa periferia lobilor inferiori, subpleurali Ingrosarea interstitiului subpleural.Ingrosarea interstitiului subpleural. Insuficienta ventriculara stanga subacuta sau cronicaInsuficienta ventriculara stanga subacuta sau cronica Boli ale mitraleiBoli ale mitralei Limfangita carcinomatoasaLimfangita carcinomatoasa Pneumonii viralePneumonii virale

Fibroza pulmonaraFibroza pulmonara Liniile Kerley C:Liniile Kerley C:

Aspect reticularAspect reticular Ingrosarea interstitiului parenchimalIngrosarea interstitiului parenchimal Apar rarApar rar


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Opacitati reticulareOpacitati reticulare Opacitatile rericulare sunt opacitati mici, poligonale, neregulate, curbe.Opacitatile rericulare sunt opacitati mici, poligonale, neregulate, curbe. Dg dif in functie de debut:Dg dif in functie de debut:

Debut acut:Debut acut: Edem interstitial (insuficienta ventriculara stanga)Edem interstitial (insuficienta ventriculara stanga) Pneumopatii acute (virale, micoplasme)Pneumopatii acute (virale, micoplasme) Modificari precoce exsudative in boli de colagen (LES)Modificari precoce exsudative in boli de colagen (LES) Reactii alergice ( posttransfuzionale sau la intepaturile de Himenoptere)Reactii alergice ( posttransfuzionale sau la intepaturile de Himenoptere)

Debut cronicDebut cronic pneumonia idiopatica interstitiala,pneumonia idiopatica interstitiala, Boli de colagen: scleroderma, poliartrita reumatoida,Boli de colagen: scleroderma, poliartrita reumatoida, asbestosis,asbestosis, pneumonia de iradiere,pneumonia de iradiere, pneumonia de hipersensibilizare stadiile finale,pneumonia de hipersensibilizare stadiile finale, reactii la medicamente,reactii la medicamente, metastaze pulmonare limfangitice ,metastaze pulmonare limfangitice ,

infectii granulomatoase terminale,infectii granulomatoase terminale, forma bronhovasculara a limfoamelor,forma bronhovasculara a limfoamelor, manifestarile bronhovasculare ale sarcomului Kaposi ,manifestarile bronhovasculare ale sarcomului Kaposi , sarcoidozasarcoidoza


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FIGURE 84-4FIGURE 84-4 Diffuse reticular lung disease.Diffuse reticular lung disease. Chest radiograph in a 94-year-old patient with diffuseChest radiograph in a 94-year-old patient with diffuse

reticular opacities due to idiopathic pulmonary fibrosis with honeycombing and tractionreticular opacities due to idiopathic pulmonary fibrosis with honeycombing and traction

bronchiectases. The lung volumes are typically reduced by a decreased pulmonary compliancebronchiectases. The lung volumes are typically reduced by a decreased pulmonary compliance..


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Aspect de fagure de miereAspect de fagure de miere

Apare in stadiile finale ale bolilor pulmonareApare in stadiile finale ale bolilor pulmonare Restructurarea anatomiei pulmonare insotita deRestructurarea anatomiei pulmonare insotita de

bronhiolectazii.bronhiolectazii. Retea dispusa in mai multe straturi, formata din spatii miciRetea dispusa in mai multe straturi, formata din spatii mici

subpleurale, intre 3-10 mm diametru.subpleurale, intre 3-10 mm diametru. Dg dif emfizem paraseptal prin: peretii mai grosi siDg dif emfizem paraseptal prin: peretii mai grosi si

dispunerea in mai multe straturidispunerea in mai multe straturi


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Leziuni alveolareLeziuni alveolare

Noduli acinari, de 0,6-1 cm, care cuprind un acinNoduli acinari, de 0,6-1 cm, care cuprind un acinanatomic si tesutul peribronhiolar din juranatomic si tesutul peribronhiolar din jur

Alte aspecte:Alte aspecte: Geam mat: umplere incompleta alveolaraGeam mat: umplere incompleta alveolara

Coalescenta unor opacitati mari,Coalescenta unor opacitati mari, Consolidarea unor intregi lobi sau segmente,Consolidarea unor intregi lobi sau segmente, Opacifierea cu distributie bronhocentricaOpacifierea cu distributie bronhocentrica Bronhograma aerica,Bronhograma aerica, Alveolograma aericaAlveolograma aerica

Opacitatile alveolare nu corespund strict anatomicOpacitatile alveolare nu corespund strict anatomicimplicarii alveolare ,implicand si interstitiulimplicarii alveolare ,implicand si interstitiul

Numite si opacitati sau condensari parenchimatoaseNumite si opacitati sau condensari parenchimatoase


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Leziuni bronsiceLeziuni bronsice

Bronsiectazii difuze: transparente liniare,Bronsiectazii difuze: transparente liniare,tubulare, chistice si opacitati care sunt distribuitetubulare, chistice si opacitati care sunt distribuitede-a lungul bronhiilor (linii de tramvai).de-a lungul bronhiilor (linii de tramvai).

Impactul mucusului (astm, aspergilozaImpactul mucusului (astm, aspergilozabronhopulmonara, bronsita plastica): opacitati cabronhopulmonara, bronsita plastica): opacitati ca: pasta de dinti, ciorchine, deget de manusa: pasta de dinti, ciorchine, deget de manusa

Plamanul murdar la fumatorii cu bronsitaPlamanul murdar la fumatorii cu bronsita

cronica: ingrosarea peretilor bronsici, fibrozacronica: ingrosarea peretilor bronsici, fibrozaperibronsica, bronsiolita, hipertensiune arterialaperibronsica, bronsiolita, hipertensiune arterialapulmonarapulmonara


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Leziuni vasculareLeziuni vasculare

Leziuni arteriale: modificari in perfuzia pulmonara:Leziuni arteriale: modificari in perfuzia pulmonara: caudalizareacaudalizarea distributia normala a vascularizatiei in ortostatism: vasele din bazeledistributia normala a vascularizatiei in ortostatism: vasele din bazele

plamanilor au diametrul de 2-3 ori mai mare decat vaseleplamanilor au diametrul de 2-3 ori mai mare decat vasele cefalizareacefalizarea=redistributia sanguina:=redistributia sanguina: raportul intre diametrele vaselor bazale si apicale esteraportul intre diametrele vaselor bazale si apicale este

inversatinversat Normal in clinostatisminl;Normal in clinostatisminl; Patologic in ortostatism: insuficienta ventriculara stanga, boala mitrala, emfizem bazalPatologic in ortostatism: insuficienta ventriculara stanga, boala mitrala, emfizem bazal

egalizareaegalizarea: fluxul sanguin egal distribuit in lobii superiori si inferiori:: fluxul sanguin egal distribuit in lobii superiori si inferiori: Circulatia hiperkinetica (anemie, obezitate, sarcina), tireotoxicoza, sunturi stanga-dreapta)Circulatia hiperkinetica (anemie, obezitate, sarcina), tireotoxicoza, sunturi stanga-dreapta) Egalizare + oligemie: hipovolemie, emfizwem difuz, sunturi dreapta-stangaEgalizare + oligemie: hipovolemie, emfizwem difuz, sunturi dreapta-stanga

centralizareacentralizarea:: dilatarea vaselor centrale pulmonare, insotita de circulatie periferica normaladilatarea vaselor centrale pulmonare, insotita de circulatie periferica normalasau.sau.

Hipertensiunea arteriala pulmonaraHipertensiunea arteriala pulmonara lateralizarea fluxului: perfuzia inegala, asimetrica, a celor 2 plamanilateralizarea fluxului: perfuzia inegala, asimetrica, a celor 2 plamani

Emfizem unilateralEmfizem unilateral Bronhiolitis obliterans unilaterala ( sindromul Swyer-James-McLeod ),Bronhiolitis obliterans unilaterala ( sindromul Swyer-James-McLeod ),

Obstructia unilaterala a unei artere pulmmonareObstructia unilaterala a unei artere pulmmonare cresterea localizata a diametrului arterialcresterea localizata a diametrului arterial::

emfizem cu distributie inegala,emfizem cu distributie inegala, Embolii multiple pulmonareEmbolii multiple pulmonare Malformatii arterio-venoaseMalformatii arterio-venoase Bronsiolitis obliterans neuniforma.Bronsiolitis obliterans neuniforma. La CT cu rezolutie inalta: perfuzie in mozaic.La CT cu rezolutie inalta: perfuzie in mozaic.


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FIGURE 84-5FIGURE 84-5 Patient with left ventricular failure.Patient with left ventricular failure. Chest frontal radiograph showsChest frontal radiograph shows

cephalization of pulmonary blood flow.cephalization of pulmonary blood flow.


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FIGURE 84-6FIGURE 84-6 Patient with primary pulmonary arterial hypertension.Patient with primary pulmonary arterial hypertension. Chest frontal radiographChest frontal radiograph

shows centralization of flow with pulmonary artery aneurysms and peripheral pulmonaryshows centralization of flow with pulmonary artery aneurysms and peripheral pulmonary

oligemia.oligemia.


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Volumul pulmonarVolumul pulmonar

Crescut:Crescut: emfizem difuzemfizem difuz astm crronicastm crronic Bronhiolita difuzaBronhiolita difuza AtletiAtleti

RedusRedus : bolile difuze infiltrative cronice pulmonare: bolile difuze infiltrative cronice pulmonare

TABEL Volumul pulmonar la bolnavi cu boli difuze pulmonareTABEL Volumul pulmonar la bolnavi cu boli difuze pulmonare Volum crescutVolum crescut: emfizem: emfizem

astm cronicastm cronicbronsiolita difuza obliternatabronsiolita difuza obliternataatletiatletilimfangioleiomiomatozalimfangioleiomiomatoza

Volum redusVolum redus: fibroza pulmonara in stadiile finale: fibroza pulmonara in stadiile finale

paralizia bilateralas diafragmaticaparalizia bilateralas diafragmatica

ascita masivaascita masiva

Volum normalVolum normal: Sarcoidosa: SarcoidosaHistiocitoza X (Langerhans )Histiocitoza X (Langerhans )

NeurofibromatosaNeurofibromatosaemfizemul cu fibroza poulmonaraemfizemul cu fibroza poulmonara


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FIGURE 84-7FIGURE 84-7 Patient with severe emphysema.Patient with severe emphysema. Chest radiograph shows hyperexpansion of bothChest radiograph shows hyperexpansion of both

lungs with bullous changes at the right lung base and leftward mediastinal shift.lungs with bullous changes at the right lung base and leftward mediastinal shift.


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Distributia anatomica a leziunilorDistributia anatomica a leziunilor

Varfurile pulmonareVarfurile pulmonare:: tuberculoza,tuberculoza, MicozeMicoze sarcoidoza,sarcoidoza, Pneumoconioze (expeptand asbestoza)Pneumoconioze (expeptand asbestoza) histiocitoza X ( Langerhans)histiocitoza X ( Langerhans) spondilita ankilopoietica,spondilita ankilopoietica, Fibroza chisticabrosis,Fibroza chisticabrosis,

Pneumonia cu Pneumocysti. jiroveciPneumonia cu Pneumocysti. jiroveci Pneumonia de iradierePneumonia de iradiere Pneumoniile de hipersensibilizare in stadiile finale.Pneumoniile de hipersensibilizare in stadiile finale.

Bazele plamanilorBazele plamanilor:: bronchiectazii,bronchiectazii, Pneumonia de aspiratie,Pneumonia de aspiratie, Pneumonia interstitiala descuamativa,Pneumonia interstitiala descuamativa, Pneumonia interstitiala nespecificaPneumonia interstitiala nespecifica reactii medicamentoase,reactii medicamentoase, asbestoza,asbestoza, sclerodermia,sclerodermia, Poliartrita reumatoida.Poliartrita reumatoida. Orice proces difuz pulmonar poate progresa in ambii plamani, fara limite zonaleOrice proces difuz pulmonar poate progresa in ambii plamani, fara limite zonale


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FIGURE 84-8FIGURE 84-8 A, Basilar pulmonary disease.A, Basilar pulmonary disease. Chest radiograph in a 48-year-old patient with knownChest radiograph in a 48-year-old patient with known

scleroderma. Bibasilar fine reticular opacities and parenchymal bands are visible in both lower lobes.scleroderma. Bibasilar fine reticular opacities and parenchymal bands are visible in both lower lobes.

B,B, Apical lung disease. Chest radiograph in a 42-year-old patient with ankylosing spondylitis. SevereApical lung disease. Chest radiograph in a 42-year-old patient with ankylosing spondylitis. Severe

architectural distortion with cicatrizing atelectasis of both upper lobes, retraction of both pulmonaryarchitectural distortion with cicatrizing atelectasis of both upper lobes, retraction of both pulmonary

arteries cephalad, and bilateral bulla formation containing fungus balls are evident.arteries cephalad, and bilateral bulla formation containing fungus balls are evident.


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GanglioniiGanglionii

Adenomegalie hilara si/sau mediastinala+ boliAdenomegalie hilara si/sau mediastinala+ bolidifuze pulmonaredifuze pulmonare sarcoidosissarcoidosis limfoame;limfoame;

micoze pulmonare;micoze pulmonare; tuberculoza;tuberculoza; pneumoconiose, mai ales silicoza si asociate cupneumoconiose, mai ales silicoza si asociate cu

berilliu (berilioza);berilliu (berilioza); neoplasm pulmonar;neoplasm pulmonar; metastaze.metastaze.


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Nodulii pulmonariNodulii pulmonari

Multiplii:Multiplii: metastaze pulmonare, HIV, sarcom Kaposi, limfoamemetastaze pulmonare, HIV, sarcom Kaposi, limfoame

o Predilectie pt regiunile subpleurale, inclusiv fisurilePredilectie pt regiunile subpleurale, inclusiv fisurileinterlobare.interlobare.

-

InfectiiInfectii- Abcese multiple prin aspiratie recurenta sau emboli septiciAbcese multiple prin aspiratie recurenta sau emboli septici- Granuloame tuberculoase sau nontuberculoase cuGranuloame tuberculoase sau nontuberculoase cu

micobacterii;micobacterii;- Micoze ( histoplasmoze, coccidioidomycosa, cryptococcosis;Micoze ( histoplasmoze, coccidioidomycosa, cryptococcosis;- Paragonimus westermaniParagonimus westermani..

- Inflamatii neinfectioase:Inflamatii neinfectioase:- Granulomatoza Wegener,Granulomatoza Wegener,- Nodulii reumatoizi,Nodulii reumatoizi,- sarcoidoza ,sarcoidoza ,- amiloidoza.amiloidoza.


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FIGURE 84-9FIGURE 84-9 Multifocal pulmonary opacities.Multifocal pulmonary opacities. Chest radiograph in a 70-year-old patient withChest radiograph in a 70-year-old patient with

known carcinoma of the thyroid gland widening the superior mediastinum and displacing the cervicalknown carcinoma of the thyroid gland widening the superior mediastinum and displacing the cervical

trachea to the right. Bilateral large and small pulmonary nodules and masses due to metastatic tumortrachea to the right. Bilateral large and small pulmonary nodules and masses due to metastatic tumor

are present.are present.


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Bolile pleuraleBolile pleurale

Rg:Rg: 75 mL obstrueaza sinusul costodiafragmatic posterior,75 mL obstrueaza sinusul costodiafragmatic posterior, 150 mL obstrueaza sinusul costo-diafragmatic lateral,150 mL obstrueaza sinusul costo-diafragmatic lateral, 200 mL produce o coaja de 1 cm grosime in decubit,200 mL produce o coaja de 1 cm grosime in decubit,

500 mL ascheaza diafragmul si se vad pe filmele in decubit500 mL ascheaza diafragmul si se vad pe filmele in decubit 1000 mL atinge nivelul arcului anterior al coastei a 4-a in1000 mL atinge nivelul arcului anterior al coastei a 4-a in

ortostatismortostatism Pot fi punctionatiPot fi punctionati 200 ml200 ml 10 ml: cantitatea minima vizibila in decubit si 175 ml minimum10 ml: cantitatea minima vizibila in decubit si 175 ml minimum

vizibil in ortostatismvizibil in ortostatism Lichid liber in cantitate medie: opacitate difuza, prin care se vadLichid liber in cantitate medie: opacitate difuza, prin care se vad

vasele pulmonare si fara bronhobrama aericavasele pulmonare si fara bronhobrama aerica


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Revarsatul pleural supradiafragmaticRevarsatul pleural supradiafragmatic

Supradenivelarea unui hemidifragm cu punctul maximSupradenivelarea unui hemidifragm cu punctul maximlaterallateral

Revarsatele mari pot duce la invertsarea diafragmuluiRevarsatele mari pot duce la invertsarea diafragmului Cresterea distantei intre baza plamanuli si punga de aerCresterea distantei intre baza plamanuli si punga de aer

a stomacului, care este deplasata infero-mediala stomacului, care este deplasata infero-medial Pleurezii inchistate: aderente pleurale; bine definite ftaPleurezii inchistate: aderente pleurale; bine definite fta

de plamanul din jur; unghiuri obtuze fata de peretelede plamanul din jur; unghiuri obtuze fata de peretele


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Placile pleuralePlacile pleurale

Acumularea pe pleura parietala a fibrelor de colagen hialinizateAcumularea pe pleura parietala a fibrelor de colagen hialinizate Expunere la azbestExpunere la azbest

Localizare predilecta: pleura parietala adiacenta PlaquesLocalizare predilecta: pleura parietala adiacenta Plaquespreferentially involve the parietal pleura adjaccoastelor Vl-lX sipreferentially involve the parietal pleura adjaccoastelor Vl-lX si

diafragmului.diafragmului. Mai putin pronuntate in spatiile intercostaleMai putin pronuntate in spatiile intercostale Nu afecteaza sinusurile costo-diafragmatice si apexulNu afecteaza sinusurile costo-diafragmatice si apexul Calcificarile se vad in 20% (Rx) si 50% (CT) cazuriCalcificarile se vad in 20% (Rx) si 50% (CT) cazuri Profil: arii focale de ingrosare pleuralaProfil: arii focale de ingrosare pleurala Calcificari curbilinii supradiafragmatice.Calcificari curbilinii supradiafragmatice. Rar calcificari interlobare in pleura parietalaRar calcificari interlobare in pleura parietala Imaginea de fata: structuri in harta geografica, punctiforme sauImaginea de fata: structuri in harta geografica, punctiforme sau

neregulate.neregulate.


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FIGURE 84-10FIGURE 84-10 Patient with known prior occupational asbestos exposure.Patient with known prior occupational asbestos exposure. Chest radiographChest radiograph

shows extensive bilateral calcified plaques seen en face, in profile, and along the diaphragmaticshows extensive bilateral calcified plaques seen en face, in profile, and along the diaphragmatic

contour.contour.


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Ingrosarea pleurala difuzaIngrosarea pleurala difuza

Apare dupa expunerea laApare dupa expunerea la Infectii,Infectii, inflamatii,inflamatii, traume,traume, tumori,tumori, tromboembolism,tromboembolism, iradiere,iradiere, asbestos.asbestos.

Cand este severa: ingrosare pleurala difuza, cu marginileCand este severa: ingrosare pleurala difuza, cu marginilenetede si grosime < 2 cm.netede si grosime < 2 cm. Rx: opacitate pleurala difuza, continua, ce ocupa cel putin unRx: opacitate pleurala difuza, continua, ce ocupa cel putin un

sfert din circumferinta peretelui toracic, oblitereaza sinusulsfert din circumferinta peretelui toracic, oblitereaza sinusulcosto-difragmatic si poate cuprinde si varfurilecosto-difragmatic si poate cuprinde si varfurile

CT ingrosare a pleurei de cel putin 3 mm.CT ingrosare a pleurei de cel putin 3 mm.


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Tumori pleuraleTumori pleurale

Mai frecvente decat tumorile benigne, mai alesMai frecvente decat tumorile benigne, mai alesmetastazele, comparativ cu mezotelioamele.metastazele, comparativ cu mezotelioamele.

Metastaze prin:Metastaze prin: Invazie pleurala de catre cancerul pulmonarInvazie pleurala de catre cancerul pulmonar Placi subpleurale in limfoame,Placi subpleurale in limfoame, Diseminare hematogenaDiseminare hematogena Extensia directa la pleura.Extensia directa la pleura.

Tumori benigne:Tumori benigne: lipoame (CT) , cele mai frecventelipoame (CT) , cele mai frecvente fibroame, origine in celulele mezenchimale pluripotente dinfibroame, origine in celulele mezenchimale pluripotente din

pleura viscerla, mai rar parietala. Pot induce sindroamepleura viscerla, mai rar parietala. Pot induce sindroameparaneoplazice: osteoartropatie, hipoglicemie; rar invadeaza sauparaneoplazice: osteoartropatie, hipoglicemie; rar invadeaza saumetastazeaza; uneori pediculate si mobilemetastazeaza; uneori pediculate si mobile

Tumori neurogene.Tumori neurogene.


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PneumotoraxulPneumotoraxul

Gaz in spatiul pleural.Gaz in spatiul pleural. Pleura viscerala este convexa, ca o linie , separata dePleura viscerala este convexa, ca o linie , separata de

pleura parietala prin spatiu aeric fara parenchimpleura parietala prin spatiu aeric fara parenchimpulmonar (nu se vad.pulmonar (nu se vad.

Rx in ortostatism: initial aerul este in spatiul apicolateral.Rx in ortostatism: initial aerul este in spatiul apicolateral. Rx in decubit: aerul se acumuleaza in sinusul costo-Rx in decubit: aerul se acumuleaza in sinusul costo-

frenic.frenic. Pneumotoraxul in tensiune:Pneumotoraxul in tensiune:

Deplasarea mediastinului controlateralDeplasarea mediastinului controlateral leads to marked shift of the mediastinum to the contralateralleads to marked shift of the mediastinum to the contralateral

aplatizarea sau inversarea hemidiafragmului ipsilateralaplatizarea sau inversarea hemidiafragmului ipsilateral


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FIGURE 84-11FIGURE 84-11 Patient with spontaneous tension hydropneumothorax.Patient with spontaneous tension hydropneumothorax. Chest radiograph showsChest radiograph shows

complete atelectasis of the left lung with a large pneumothorax and a left basilar gas-liquid level. Thecomplete atelectasis of the left lung with a large pneumothorax and a left basilar gas-liquid level. The

patient had primary tuberculosis.patient had primary tuberculosis.


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Imaginea radiologica a mediastinuluiImaginea radiologica a mediastinului

Mediastinul este delimitat de :Mediastinul este delimitat de : Apertura toracica;Apertura toracica; coloana vertebralacoloana vertebrala Sternul;Sternul;

Pleurele mediastinalePleurele mediastinale

Tehnica:Tehnica: Pe filmele cu penetrabilitate buna se evidentiaza liniilePe filmele cu penetrabilitate buna se evidentiaza liniile

din fig 84-12.:din fig 84-12.:


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FIGURE 84-13FIGURE 84-13 A, Patient with anterior mediastinal teratoma.A, Patient with anterior mediastinal teratoma. Chest radiograph shows a mediastinal contourChest radiograph shows a mediastinal contour

abnormality due to projection of the mass into the right hemithorax. Note the obtuse angle of interface formed by theabnormality due to projection of the mass into the right hemithorax. Note the obtuse angle of interface formed by the

pleura covering the mass with the mediastinum.pleura covering the mass with the mediastinum. B,B, Patient with Castleman's giant lymph node hyperplasia. ChestPatient with Castleman's giant lymph node hyperplasia. Chest

frontal radiograph shows large subcarinal middle mediastinal mass that projects lateral to the right atrium.frontal radiograph shows large subcarinal middle mediastinal mass that projects lateral to the right atrium. C,C, PatientPatient

with paraspinal ganglioneuroma. Chest radiograph shows right lower paraspinal contour abnormality widening the rightwith paraspinal ganglioneuroma. Chest radiograph shows right lower paraspinal contour abnormality widening the right

paraspinal region and encompassing the height of three thoracic vertebrae.paraspinal region and encompassing the height of three thoracic vertebrae.

FIGURE 84 12FIGURE 84 12 Chest radiograph with superimposed mediastinal stripesChest radiograph with superimposed mediastinal stripes Yellow: rightYellow: right


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FIGURE 84-12FIGURE 84-12 Chest radiograph with superimposed mediastinal stripes.Chest radiograph with superimposed mediastinal stripes. Yellow: rightYellow: right

paratracheal stripe. Light blue: right and left paraspinal stripes. Red: azygoesophageal stripe. Brown:paratracheal stripe. Light blue: right and left paraspinal stripes. Red: azygoesophageal stripe. Brown:

pleuroesophageal stripe. Purple: anterior junction line complex. Pink: left subclavian artery border.pleuroesophageal stripe. Purple: anterior junction line complex. Pink: left subclavian artery border.

Light green: posterior-superior junction line. Dark green: para-aortic lineLight green: posterior-superior junction line. Dark green: para-aortic line..


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Compartimentele mediastinuluiCompartimentele mediastinului Mediastinul anteriorMediastinul anterior: contine timusul (sau tesutul gras care il inlocuieste) si ganglioni.: contine timusul (sau tesutul gras care il inlocuieste) si ganglioni.

Patologic:Patologic:

thymoame,thymoame, lymfoame,lymfoame, teratome si alte tumori germinaleteratome si alte tumori germinale Gusa substerna,Gusa substerna, lipoame,lipoame, hemangioamehemangioame lymphangioame.lymphangioame.

Mediastinul mediuMediastinul mediu: subdivizat:: subdivizat: spatiul subcarinal ,spatiul subcarinal , Regiunea paratraheala,Regiunea paratraheala, Regiunea retrotraheala,Regiunea retrotraheala, Fereastra aorto-pulmonara,Fereastra aorto-pulmonara, Spatiu retro-cardiac.Spatiu retro-cardiac.

Patologic: adenopatii , malformatii bronhopulmonarePatologic: adenopatii , malformatii bronhopulmonare Retrotraheal: In the retrotracheal region, artera subclaviculara dreapta aberanta; gusa plonjanta posterioara , tumoriRetrotraheal: In the retrotracheal region, artera subclaviculara dreapta aberanta; gusa plonjanta posterioara , tumori

esofagiene, diverticuli, chiste ale ductului toracic .esofagiene, diverticuli, chiste ale ductului toracic . Fereatra aorto-pulmonara: canal arterial patent; malformatii bronhopulmonare; anevrisme aortice sau pulmonare.Fereatra aorto-pulmonara: canal arterial patent; malformatii bronhopulmonare; anevrisme aortice sau pulmonare.

Mediastinul posteriorMediastinul posterior: regiunea paraspinala:: regiunea paraspinala: Patologic:Patologic: tumori neurogene din lantul simpatic sau din radacinile nervoasetumori neurogene din lantul simpatic sau din radacinile nervoase Hematopoieza extramedulara: mase paravertebrale rezultate din maduva osoasa care protruzeaza din coaste sau dinHematopoieza extramedulara: mase paravertebrale rezultate din maduva osoasa care protruzeaza din coaste sau din

corpiui vertebralicorpiui vertebrali Adenopatii: metastaze, limfoameAdenopatii: metastaze, limfoame Boli ale coloanei vertebrale: spondilita bacteriana sau TBC, tumori, hematoame posttraumaticeBoli ale coloanei vertebrale: spondilita bacteriana sau TBC, tumori, hematoame posttraumatice


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extrapleural pneumonolysis (plombage) with polymethyl methacrylate balls forextrapleural pneumonolysis (plombage) with polymethyl methacrylate balls for

the treatment of tuberculosis. The balls are visible in the radiograph.the treatment of tuberculosis. The balls are visible in the radiograph.


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tracheal deviation. Ultrasonography of the neck revealed a large goiter with thetracheal deviation. Ultrasonography of the neck revealed a large goiter with the

right lobe extending into the anterior superior mediastinum.right lobe extending into the anterior superior mediastinum.


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A pulmonary mass is visible in the left upper lung.A pulmonary mass is visible in the left upper lung.


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diffuse bilateral ground-glass opacitydiffuse bilateral ground-glass opacity

FindingsFindings
http://eradiology.bidmc.harvard.edu/Classics/default.aspx


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FindingsFindings

Air is lucent (jet black) on plain film.Air is lucent (jet black) on plain film.

There is streaky air in the subcutaneous tissue bilaterally.There is streaky air in the subcutaneous tissue bilaterally.
http://eradiology.bidmc.harvard.edu/Classics/default.aspx


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